Nokea
For each potential prescription, click to specify whether the prescription is expected or not expected for the care of the client.
- A. Administer IV antibiotics
- B. Prepare client for echocardiography
- C. Initiate low-flow supplemental oxygen
- D. Gather supplies for pericardiocentesis
- E. Place peripherally inserted central catheter (PICC)
- F. Collect a blood specimen for culture and sensitivity
Correct Answer:
Rationale: Expected prescriptions for clients with suspected infective endocarditis (IE) include:
• Administering IV antibiotics to kill the infectious pathogen
• Preparing the client for echocardiography to identify valvular dysfunction, chamber enlargement, and vegetations
• Placing a peripherally inserted central catheter for long-term IV antibiotic therapy
• Collecting a blood specimen for culture and sensitivity to identify the infectious pathogen
Initiating low-flow supplemental oxygen is not expected because the client is not exhibiting signs of respiratory distress.
Pericardiocentesis is performed to remove excess fluid from the pericardial cavity and prevent progression to cardiac
tamponade. Pericardial effusions are not commonly expected with IE. Furthermore, this client is not exhibiting signs of
pericardial effusion (eg, muffled heart sounds, substernal pain). Therefore, gathering supplies for pericardiocentesis is not
expected.
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Select below the 4 findings that are most concerning at this time.
- A. controlled hypertension, hypercholesterolemia, and mitral valve prolapse and regurgitation.
- B. T 100.4 F (38 C),
- C. Thin, brown longitudinal lines on
several nail beds. - D. 2 teeth extracted 3 weeks ago;
- E. general malaise, fever and chills, night sweats, fatigue,
and poor appetite. - F. erythematous macular lesions on both palms
Correct Answer: B,C,D,F
Rationale: This client has multiple findings concerning for infective endocarditis (IE), which occurs when an infectious organism enters the
innermost layer of the heart (ie, endocardium) and forms a vegetation on a heart valve. Findings concerning for IE include:
• Recent tooth extraction: Dental procedures (eg, tooth extraction) increase the risk for infectious organisms entering the
bloodstream, potentially leading to IE. Other risk factors include a history of IV drug use, presence of a distant infection
(eg, leg cellulitis), or presence of a prosthetic heart valve
• Fever: Elevated temperature is a sign of infection, which is a common finding in clients with IE.
• Nontender, erythematous, macular lesions on the palms or soles (Janeway lesions): Janeway lesions are
characteristic of IE. They occur when turbulent blood flow through the heart valves causes pieces of endocardial
vegetation to break off, forming microemboli that travel through the arteries to end-capillaries and block blood flow.
• Nonblanching, thin, red/dark longitudinal lines under the nail beds (splinter hemorrhages): Like Janeway lesions,
splinter hemorrhages are caused by microemboli that break off from vegetative lesions in the heart and travel through the
arteries to end-capillaries and block blood flow.
I can never get tuberculosis again once I finish treatment
- A. I should take the medications with antacids.
- B. I will notify my health care provider if my urine becomes orange.
- C. I will use additional contraception while taking rifampin
Correct Answer: D
Rationale: Rifampin is often used in the management of both latent and active tuberculosis (TB) but reduces the effectiveness of oral contraceptive
pills. Therefore, the client should be instructed to use additional methods of contraception during treatment and for 1 month following
the completion of treatment (Option 4).
The nurse has reviewed the information from the Laboratory Results. Which of the following conditions should the nurse suspect? Select all that apply.
- A. Attention deficit hyperactivity disorder
- B. Major depressive disorder
- C. Posttraumatic stress disorder
- D. Schizophrenia
- E. Substance use disorder
Correct Answer: B,E
Rationale: Major depressive disorder (MDD) is characterized by a persistent (duration ≥2 weeks) depression in mood (eg, sadness,
social withdrawal) that interferes with daily life. This client has several clinical manifestations of MDD, including loss of interest
in daily activities, significant change in appetite or weight, persistent feelings of worthlessness, recurrent thoughts of self-harm,
inattention, and fatigue. MDD is a significant risk factor for suicide
Substance use disorder is the recurrent use of alcohol and/or recreational drugs that results in interpersonal dysfunction,
impaired control, and physical effects (eg, withdrawal). This client's urine drug screen is positive for cocaine and marijuana
Therefore, the nurse should further investigate the client's substance use (eg, amount, frequency, route of administration, date
of last use, perceived benefits, negative consequences)
Drag words from the choices below to fill in the blank/blanks. The nurse should immediately follow up on the client's-----------------------and-----------
- A. Weight gain
- B. Blood pressure
- C. Respiratory findings
- D. Lower extremity edema
Correct Answer: C,B
Rationale: Heart failure (HF) is a chronic, progressive condition characterized by impaired ventricular function that leads to decreased cardiac output and
causes blood to back up into the lungs and systemic circulation. This results in fluid volume overload that is commonly treated with diuretics,
such as furosemide (ie, "water pill"), that remove excess fluid through increased urination.
A client with HF who is experiencing dyspnea, inspiratory crackles, weight gain, and peripheral edema is demonstrating fluid volume overload
from a probable acute HF exacerbation. The nurse should immediately follow up on potentially life-threatening findings such as the client's:
• Blood pressure, which is moderately elevated and requires urgent intervention with medications (eg, diuretics). Fluid overload causes
increased pressure in the blood vessels, leading to hypertension that increases afterload. This is especially concerning for HF because
the heart muscle is already weak and cannot withstand additional afterload.
• Respiratory findings (ie, capillary oxygen saturation [SpOz) 90% on room air, inspiratory crackles, tachypnea, dyspnea, labored
respirations) because these likely indicate pulmonary edema. Crackles are a manifestation of pulmonary edema caused by fluid in the
alveoli that leads to impaired gas exchange and hypoxemia.
(Incorrect) Weiaht aain and lower extremity edema are also indicators of fluid volume overload however these findinas are not directly life
The nurse has reviewed the information from the Laboratory Results and Nurses' Notes. Which of the following nursing actions are anticipated? Select all that apply
- A. Adds 5% dextrose to continuous IV fluids
- B. Administers potassium chloride
- C. Administers sodium bicarbonate
- D. Discontinues insulin infusion
- E. Encourages the client to drink orange juice
Correct Answer: A,B
Rationale: The goal of treatment of diabetic ketoacidosis (DKA) is to normalize fluid volume, decrease blood glucose levels, balance electrolytes, and
correct metabolic acidosis. On administration of insulin, potassium and glucose shift from the extracellular space to the intracellular space.
Clients with DKA require potassium administration due to low intracellular potassium levels.
Insulin is administered to facilitate glucose transport into the intracellular space to resolve DKA and should be continued until the metabolic
acidosis resolves. When caring for clients with DKA, the nurse should anticipate:
• Adding 5% dextrose to continuous IV fluids when the serum blood glucose level reaches approximately 200 mg/dL (11.1 mmol/L) to
prevent hypoglycemia and cerebral edema resulting from levels decreasing too quickly (Option 1). This is done because insulin is still
required to resolve DKA. If the DKA is resolved, insulin can also be decreased instead of adding dextrose to the IV fluids.
• Administering potassium chloride for a client with hypokalemia and adequate urine output (ie, >30 mL/hr) to prevent life-threatening
arrhythmias